Patient Registration
Please complete the following confidential information
If this appointment is for you start here
If this appointment is for your child start here
If your child's last name and or address are not the same as yours then fill in the top box also
Dental Insurance
Primary Carrier
Secondary Carrier
Account Information
Person financially responsible for account
Your Spouse
Getting to know you
Is another member of your family or relative a patient at our office?
You were referred to us by?
Person to contact for emergency
Dental History
Have you ever used or are you currently using topical fluoride?
Do you have any dental problems now?
Are any of your teeth sensitive to:
Hot or cold?
Biting or Chewing?
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other oral legions?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
Does food tend to become caught in between your teeth?
Do you:
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth? (pencils, pipe, etc.)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Snore or have any other sleeping disorders?
Smoke/chew tobacco or use other tobacco products?
Have you ever had:
Orthodontic treatment?
Oral Surgery?
Periodontal treatment?
Your ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
Have you experienced:
Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neckaches or shoulder aches?
Sore muscles (neck, shoulders)?
Are you satisfied with your teeth's appearance?
Would you like to replace your silver fillings?
Would you like to keep all of your teeth all of your life?
So you feel nervous about having dental treatment?
Have you ever had an upsetting dental experience?
Have you ever been told to take a pre-medication prior to dental treatment?
Is there anything else about having dental treatment that you would like us to know?
Medical History
Have you had any medical care within the past two years?
Have you taken any medication or drugs during the past two years?
Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?
Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other bisphosphonates?
Are you aware of having an allergic (or adverse) reaction to any substance or medication?
Have you been a patient in the hospital during the past five years?
Indicate which of the following you have had, or have at present. Select "yes" or "no" to each item.
Heart (Surgery, Disease, Attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
High/Low Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve/Pacemaker
Rheumatic Fever
Cortisone Medicine
Swollen Ankles
Diet (Special/Restricted)
Artificial Joints (hip, knee, etc.)
Kidney Trouble
Thyroid Problems
Contact lenses
Chronic Cough
Hay Fever/Allergy/Hives
Latex Sensitivity
Sinus Trouble
Radiation Therapy
Venereal Disease
A.I.D.S./H.I.V. Positive
Cold Sores/Fever Blisters
Blood Transfusion
Sickle Cell Disease
Bruise Easily
Liver Disease/Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Psychiatric/Psychological Care
Have you lost or gained more than 10 pounds in the past year?
Do you have or have you had any disease, condition, or problem not listed?
Women: Are you pregnant or think you could be pregnant?
Do you use birth control prescriptions?

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

Consent for treatment
  1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of s dental needs.
  2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
  3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
  4. I give consent to the doctors or designated staff's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose or carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
  5. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.
Irwin Dentistry
Notice of Privacy Practices


We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).


Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.10 for each page, $15 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations, {You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.


If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Brandi

Telephone: 562-697-2500 Fax: 562-905-2095

Address: 731 N. Beach Blvd. Suite 150 La Habra, CA 90631

Email: appointments@irwindentistry.corn

Consent for Internet Communications
For Office Use Only

I grant my permission to Irwin Dentistry to upload and store confidential patient information — including account information, appointment information and clinical information — to the secured web site for Irwin Dentistry. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand Irwin Dentistry and myself are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that Irwin Dentistry is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand Irwin Dentistry is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the Irwin Dentistry web site with my ID and password. I also agree to immediately notify Irwin Dentistry of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I also understand State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand Irwin Dentistry will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my patient information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that Irwin Dentistry has the right to monitor, retrieve, store, upload and use my patient information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand Irwin Dentistry will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand Irwin Dentistry CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

I have read the information above regarding the secured uploading of patient information to the web site for Irwin Dentistry, and grant Irwin Dentistry permission to securely upload my patient information to the web site.

General Photo Release

I hereby grant to Dr. Steve Irwin and to any of his/her assigns, the absolute and irrevocable right and permission, with respect to the photographs taken of me, or in which I may be included with others; to use, re-use, and/or publish the same in whole or in part, individually, or in conjunction with photographs, without limitation in perpetuity. These photographs shall be used specifically and exclusively for the purpose of dental education, or dental procedure awareness, or dental procedure promotion.

I hereby release and discharge Dr. Irwin and assigns, from any and all claims and demands arising out of or in connection with the use of the photographs, including any and all claims for libel.

I hereby convey and assign all rights contained above herein to another doctor or vendor for the purpose of dental education, or dental procedure awareness, or dental practice promotion.